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It
sounds like the perfect drug. At low doses, it's stimulating, like a strong cup
of coffee; at higher doses, it's sedating and kills pain. And it's a legal,
natural plant that has been used in Asian medicine for centuries. Indeed, a growing number of Americans are finding
it to be a useful alternative to heroin and prescription pain relievers.

But
of course, there's a catch. Like the opioid drugs it is used to replace, this
stuff can be addictive, and it can also cause serious nausea. Unlike other
opioids, however, it seems to have an extremely low
overdose risk, which has caught the eye of people working to fight the record
high level of overdose deaths.

It's
called
kratom. And while some harm reductionists and thousands of pain patients
see it as a possible path to relief and recovery, recent media attention in the
New York Times and elsewhere has focused on it
primarily as a
drug of abuse. As a result, kratom
may soon be prohibited, rather than properly studied. The data so far, however,
suggests that banning it might do more harm than good— and that new more
flexible ways of regulating drugs may be needed in order to truly protect the
public.

Kratom
is an unusual substance, with a storied history of use in Thailand and
Malaysia, typically to fortify workers, treat diarrhea, and reduce pain. As far back as the 1940s, it was known to
relieve symptoms of opium withdrawal; in fact, it was actually
banned by the Thai government
in 1943 precisely because its use as a substitute led to decreased revenues
from opium taxes.

But
because kratom use in the US was historically rare, and because herbal
medicines and supplements are lightly regulated, the plant is currently legal
in all but four American states. The Drug Enforcement Administration (DEA),
however, has placed it on its list of "
drugs of concern," which is often a
precursor to a ban. Meanwhile,
New York and Florida lawmakers are both currently considering bans of their own.

Check out our documentary about medical marijuana use by sick children.

Usually
consumed as a tea made from the leaves of the Mitragyna speciosa plant, the
main active ingredients of kratom have been identified as mitragynine and a
related substance, 7-hydroxymitragynine. These chemicals activate opioid
receptors, just like heroin and Oxycontin can. However, both the high that
results and the tolerance and withdrawal that can occur after long-term use
pale in comparison to those from heroin and painkillers, according to users.

"It's
not as sweet, but it is relaxing, calming," one user, a former heroin addict,
told me, comparing the two drugs. Also, while opioids tend to be sedating,
kratom initially has a stimulating effect— users compare it to a serious
caffeine buzz, and indeed, the plant is a member of the same species as coffee.
With higher doses, the energizing effect is followed by a more relaxing, mellow
feeling.

Probably
the most important difference between kratom and other opioids, however, is the
risk of overdose. While a record-high
28,647 Americans died of
opioid-involved (typically multi-drug) overdose in 2014, according to the CDC, even
on their own, opioids can kill. In contrast, the
fewreported kratom-linked deaths
have all involved multiple drugs.

Moreover,
even the kratom mixture deaths don't kill via cessation of breathing, which is
a hallmark of opioid overdose. "Direct kratom overdoses from the life-threatening
respiratory depression that usually occurs with opioid overdoses have not been
reported," says Oliver Grundmann, clinical associate professor of medicinal
chemistry at the University of Florida, who recently
reviewed the research on kratom for the International Journal of Legal Medicine.

That's
probably because kratom tea and powders are both bulky and frequently nausea-inducing,
particularly in high doses—so it would be physically difficult for most people
to actually keep enough down to be dangerous. And given its lengthy history of
medicinal use in Asian countries, if there was a significant risk from acute
overdose, it should have been reported by now.

Susan
Ash, a chronic pain patient and the founder of the
American Kratom Association, started taking kratom
when she was trying to end her dependence on opioid pain medication. Suffering
from the lingering effects of Lyme disease, she had severe joint pain, but
realized that she was starting to misuse her prescription pills and decided to
stop.

As
she did so, someone in an online support group suggested that she try kratom,
both to relieve pain and ease withdrawal. "I thought she was crazy," Ash recalls.
But she eventually decided to try it, and when she got the dose right, found
that it allowed her to stop the other opioids and function better than she had
before. "It literally changed my life,"
she says.

Her
organization now has 250 dues-paying members and over 2,400 regular
participants in a closed Facebook page discussion group for people who take it,
Ash says. While the group doesn't take donations directly from kratom
manufacturers or suppliers, she says it may receive some money from people
employed in the business. "We don't endorse any companies," she says.

Ash,
who has a master's in forestry science but has been on disability due to her
pain, has
taken kratom daily for around a year and a half. "I really don't experience
much aside from pain relief and a little jump in energy, which is important
because I still deal with chronic fatigue," she says.

But
because there is little history of kratom use in the US, there is also not much
research on its effects—negative or positive. Mark Swogger, an assistant
professor of psychiatry at the University of Rochester Medical Center, and his
colleagues analyzed 161 "experience reports" posted by kratom users on the drug
information site Erowid.org for a recent
study in the Journal
of Psychoactive Drugs
. When asked what is known about negative outcomes, Swogger
says, "I think it's pretty safe to say that kratom has at least some addiction
potential. The data is fairly strong on that and our study also found that
people are reporting addiction."

However,
he adds, "Overall, we found that it's really mild compared to opioid addiction
and it didn't seem to last as long." The
most commonly reported negative experience was nausea or stomach pain, which 16
percent of the users experienced. And almost 6 percent actually vomited. "I know people personally who have taken
small doses and had miserable experiences," he says, mentioning "days" of
throwing up.

Two
of the study participants reported severe side effects such as jaundice and
hepatitis, which required medical attention. Both recovered fully, but one
reported liver enzymes that were still elevated six weeks later. There have
also been a few
case reports of liver
problems and
seizures. Moreover, the long-term effects of taking the
stuff are simply unknown: As pharmaceutical manufacturers have found, sometimes
rare but damaging side effects only emerge after millions of people have taken
a drug for years. "We don't know that
much about kratom," says Grundmann. "We have to evaluate the adverse effects
and do clinical studies."

All
of this makes for a vexing regulatory challenge. If kratom were a newly developed synthetic
addiction medication, no one would dream of allowing it on the market without
clinical testing. But because it's a
supplement with a long history of use in herbal medicine, the rules are
different.

Since
1994, even herbs that contain clearly pharmacologically active substances are
allowed to be sold over the
counter without testing if they have previously been used medically—unless they
are proven to be harmful and as long as they aren't claimed to cure or treat
medical disorders. That's the exact
opposite of the way the FDA regulates medicines, which must be determined to be
safe and effective through a
process of clinical testing
before they can be sold.

Usually,
the FDA testing process works reasonably well to balance public safety and the
need for medical progress. But the regulation of supplements has far more
loopholes, and there is no path at all for regulating recreational drugs—the
only action ever taken tends to be absolute prohibition. To get a medical drug
approved requires millions of dollars worth of investment, takes years, and
needs to provide viable intellectual property rights to the pharmaceutical
industry in order to get them to take the risk. That's a heavy lift for
plant-based substances that can't be patented in and of themselves.

This
is a problem. In the case of kratom, during an epidemic of opioid misuse which
is absolutely known to be rapidly killing people, it seems odd to call for a
ban of a substance that, whatever its long term risks are, is clearly safer in
the short term. And yet that is what recent media coverage seems to suggest
should happen—the
New York Times
piece, for example, was headlined, "Kratom, an Addict's Alternative, Is Found to
Be Addictive Itself," and it highlighted the drug primarily as a path to
relapse for people seeking to be abstinent.

Given
all of the other opioids typically involved in relapse—including the
life-saving maintenance medications
methadone and buprenorphine—can themselves be deadly, this seems short-sighted.
Yes, there clearly are unknown risks for people who take this drug as an
alternative to opioids, and it certainly shouldn't be sold to children.

But
perhaps, as the federal government is now doing with the legal weed states, it
might be wise just to let those who use and distribute it alone for now—and in
the meanwhile, fund research on what could be the safest form of opioid
painkiller and maintenance drug on the planet.

To
deal with recovering people who fear the temptation to take it, sellers in the
Netherlands—far ahead of America as usual—have developed a solution that could
easily be adopted here. Kratom is legal there, but the "smart shops" that sell
it recognize that some people do become problem users. To help them, some stores
allow customers to voluntarily place themselves on a "blacklist," for a certain
period of time, during which they will not be permitted to buy, even if they
ask for a change of status.

Such
measures could be used in the United States, too—but only if we begin to think
more flexibly about harm reduction and risk, rather than continually adding new
prohibitions without considering whether, in context, the lesser of the evils
may save lives.